Every finding on record at Waters of Martinsville, The

Based on observation, interview, and record review, the facility failed to ensure food was served in a safe and sanitary manner for 2 of 2 kitchen observations. Hairnets were not worn while preparing food, the dishwashing room was dirty, and expired foods were not discarded. Findings include:1. During a tour of the kitchen on 1/29/26 from 7:40 a.m. until 8:05 a.m., the following was observed.- The Activity Director and the Social Service Director were working in the kitchen, preparing meal trays, without wearing a hair net. At that time, the Social Service Director indicated they should have put on hair nets before working in the kitchen. - Inside the walk-in refrigerator observed a plastic one-gallon jug of [NAME] Chere Old Fashion Ranch Dressing with an open date of 12/29/25, and an expiration of on 12/12/25 (The dressing was opened after the expiration date). At that time, the Dietary Manager indicated the expired ranch dressing should have been removed from the refrigerator.- A buildup of debris and food particles were observed on the top of the dishwasher and along the floor underneath the metal dishwasher tables. At that time, the Dietary Manager indicated the dishwasher and dish room floors should have been cleaned thoroughly.2. On 1/30/26 at 8:24 a.m., inside the walk-in refrigerator observed two full plastic, one-gallon jugs of [NAME] two percent milk. The expiration date on both of the milk jugs was 1/29/26. At that time, the Regional Dietary Director indicated the expired milk should have been removed from the refrigerator. On 1/30/26 at 9:00 a.m., the Administrator provided a copy of a facility policy, titled Food Storage, dated 11/29/19, and indicated this was the current policy used by the facility. A review of the policy indicated food should be storage and prepared in a clean, safe, and sanitary manner.This citation relates to Intakes 2725718 and 2700986.3.1-21(i)(2)3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure a sanitary and safe environment for 2 of 2 random observations. Linens were not clean, soiled briefs were left in garbage cans, and odors were present. (room [ROOM NUMBER], room [ROOM NUMBER])1. On 1/29/26 at 8:25 a.m., inside room [ROOM NUMBER] observed a large orange/brown stain on the fitted sheet on Bed B (window bed) and one urine soiled brief in the garbage can inside the bathroom. The bathroom had a strong urine odor. The bathroom was shared between room [ROOM NUMBER] and room [ROOM NUMBER]. At that time, Resident B indicated she couldn't remember when her sheets had been changed last and when she changed her own briefs, she threw her used soiled briefs in the garbage can in the bathroom.During an interview on 1/29/26 at 8:42 a.m., Resident C indicated her room had a shared bathroom with Resident B's room. Resident C had taken herself to the bathroom because she liked doing things for herself and had placed her own soiled briefs in the garbage can. On several occasions, Resident C noticed soiled briefs in the garbage can that she did not put in there. During an interview on 1/29/26 at 8:44 a.m., CNA 1 indicated soiled briefs should not have been left in Resident B and Resident C's bathroom garbage can. The staff should have checked the garbage cans and removed the garbage bags and soiled briefs.2. On 1/29/26 at 9:05 a.m., there was a strong urine odor in room [ROOM NUMBER]. Resident D was lying on Bed B without any sheets on her bed. Resident D was covered with a small fleece blanket. At that time, Resident D indicated she was not sure where the urine odor was coming from. Resident D couldn't remember when she had sheets on her mattress last. On 1/30/26 at 8:44 a.m., observed Resident D sitting up in her wheelchair inside her room. A fleece blanket had been thrown on top of Bed B and did not have any linens. The fleece blanket was saturated with urine and the mattress was wet. At that time, Resident D indicated the staff had not put any linens on her mattress yesterday nor today. Resident D couldn't remember the last time her blanket had been cleaned. On 1/30/26 at 2:45 p.m., the facility was unable to provide a policy.This citation relates to Intake 2711983.3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 1 of 3 kitchen observations. Hair was not covered, food was not labeled or discarded by manufacturer's use by date, floors and other surfaces required cleaning, and a scoop was kept in dry storage goods. These had the potential to affect 52 of 53 residents residing in the facility. (Dietary Aide 2)Findings include:During an observation of the kitchen on 10/22/25 from 12:20 p.m. to 12:50 p.m., the following was observed.-Dietary Aide 2 was observed in and around the food preparation areas. Dietary Aide 2 was observed to lack hair coverage to hair out the back and side of hair net, hanging down back and on the shoulders approximately six to eight inches in length past the hair net. -In a two-door refrigerator on the left-hand side, one full half gallon of 100 percent lactose free two percent milk with a best by date of 10/17/25. -In the walk-in refrigerator unit, on the middle left side shelf, one partially uncovered metal tray of red gelatin looking substance was unlabeled and undated.-In the walk-in refrigerator unit, on the middle right side shelf, metal plastic covered container with a handwritten label was noted as bacon grease, had an open date of 10/13/25 and a use by date of 10/16/25. -In the walk-in refrigerator unit, on the middle right side shelf, metal plastic covered container with a handwritten label was noted as ham, had a prepared date of 10/18/25, and lacked a use by or best by date. -In the walk-in refrigerator unit, on the middle right side shelf, a clear red topped container with handwritten label noted as ground beef, had a use by date of 10/21/25. -The walk-in refrigeration unit was noted to have a visibly soiled and dirty floor, with dark colored substance noted under the wire racks, on the right side most heavily, with food debris and an upside-down small plastic juice container that appeared to be leaking. -In the dry goods storage area a plastic scoop was located inside the clear flour bin. -In the open doorway of dry storage area, a large black trash bag was sitting on the floor full of dirty linens. -Outside of the dry goods storage area, close to the walk in refrigeration area was a white plastic trash bin labeled Dietary Rags, the trash bag inside was crumpled up at the bottom of the bin and a few food items were noted in the bottom. -The walk-in freezer had the furry, black-gray and blue substance located on the outside the bottom right area of the door. -The walk-in freezer had the daily temperature check records, where the walk in refrigeration unit and the walk-in freezer unit were each to have temperatures recorded multiple times daily, the temperatures for the morning checks for 10/22/25 were blank for both the walk-in refrigerator and walk-in freezer. During an interview on 10/22/25 at 12:55 p.m., the Dietary Manager (DM) indicated the following; staff hair should be covered in the kitchen and food preparation areas, the floors should be clean, scoops should not be stored in dry goods bins, linens should be in appropriate containers, all food items should be labeled appropriately and discarded by or before the expiration date, and the temperatures for the walk-in freezer and walk-in refrigerator should have been marked for earlier that morning. During an interview on 10/22/25 at 1:10 p.m., the Administrator indicated that all staff in the kitchen should have their hair covered, and that appropriate food safety and sanitation measures should be in place. On 10/22/25 at 1:50 p.m., the Administrator provided a copy of a section of the Food Safety & Sanitation policies and procedures manual for the facility, titled Dating and Labeling and dated April of 2017, and indicated it was the policy currently in use by the facility. A review of the policy indicated that all foods are to be stored, dated, and labeled appropriately including labeling accurate identification of the food and the use-by dates. On 10/22/25 at 2:00 p.m., the Administrator provided a copy of a section of the Food Safety and Sanitation policies and procedures manual for the facility, titled Receiving and Handling and dated April of 2017, and indicated it was the policy currently in use by the facility. A review of the policy indicated, Hair restraints will be worn at all times. The policy further indicated safe food and handling practices include checking expiration dates and checking temperatures for storage areas.This citation relates to Intake 2644592.3.1-21(i)(2)3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure the written notification required for a transfer/discharge was provided to the resident and the resident representative for 2 of 4 residents reviewed for hospitalization and discharge. (Resident 8, Resident 66) Findings include: 1. On 9/25/25 at 10:30 a.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and delusional disorder (a mental health condition characterized by persistent, false beliefs (delusions) that are not based on reality). A review of the resident's progress notes indicated the resident was transferred to the emergency room on 7/27/25 and returned to the long-term care facility on 7/30/25. . The clinical record lacked documentation that a written notice was provided to the resident and resident representative. During an interview with the Director of Nursing (DON) on 9/26/25 at 2:19 p.m., she indicated they did not have documentation that the resident and resident representative received a written notice of transfer/discharge. 2. On 9/29/25 at 10:40 a.m., Resident 66's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction and aphasia. The resident was admitted to the facility on [DATE] and discharged to the hospital on 8/2/25. The clinical record indicated no transfer/discharge notification was provided to the resident or resident's representative in writing. During an interview on 9/29/25 at 2:30 p.m., the Director of Nursing indicated no transfer/discharge notification was provided to the resident or resident's representative in writing. On 9/29/25 at 9:45 a.m., the Administrator provided the facility policy labeled Bed Hold, Transfer and Discharge Policy and Procedure, she indicated this was a current policy used by the facility. A review of the policy indicated .It is the policy of the facility to provide the Resident, Resident's family member and/or the Resident's legal representative, if applicable a written form . prior to transfer to a hospital .certain information regarding the Resident's facility bed status .6. Explain transfer and reason to the resident and/or representative if applicable send the original State Transfer/Discharge/Bed hold notice with the resident and/or representative .Place the facility copy in the health record . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on record review and interview, the facility failed to ensure residents were informed of and participated in their treatment plan for 1 of 2 residents reviewed for mood and behavior. (Resident 36)Finding includes:On 9/25/25 at 2:19 p.m., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety disorder, depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and dementia.A review of the resident's physician orders indicated from 7/31/25 to 8/12/25 the resident was prescribed Risperdal (antipsychotic medication) 0.5 milligrams (mg) twice daily for bipolar episodes. On 8/13/25, an order indicated the Risperdal was increased to 1 milligram (mg) twice daily.The clinical record lacked an informed consent for the increase of the antipsychotic medication on 8/13/25.During an interview with the Director of Nursing (DON) on 9/26/25 at 11:34 a.m., she indicated there was no documentation that an informed consent was provided prior to the resident receiving the increased dose of Risperdal.On 9/29/25 at 9:45 a.m., the Administrator provided a copy of the facility's Guidelines for psychotropic medication, dated 6/25/23, she indicated this was a current policy used by the facility. The guideline indicated, .Obtain Informed Consent .from the resident and/or resident representative as appropriate, and document education to include: .c) side effects/adverse consequences, d) risks vs Benefits .f) dose changes-if they occur, g) Document this education and form completion in Nurses' Notes .3.1-3(n)(2)

Based on interview and record review, the facility failed to protect the residents right to be free from physical and verbal abuse by another resident for 1 of 2 residents reviewed for abuse. (Resident 4, Resident 18)Findings include:On 9/24/25 at 10:12 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to depression, anxiety, and post-traumatic stress disorder.An 9/16/25 annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.During an interview on 9/29/25 at 11:16 a.m., CNA 3 indicated Resident 4 was often aggressive with staff and other residents. She was aware of Resident 4 hitting Resident 18 on the head. During an interview on 9/29/25 at 11:20 a.m., LPN 2 indicated Resident 4 had an aggressive affect and she was aware of Resident 4 hitting Resident 18 on the head. During an interview on 9/29/25 at 12:10 p.m., the Administrator (ADM) indicated Resident 4 struck Resident 18 in the face after an altercation. Resident 18 shouted at another resident to stop screaming and Resident 4 went across the hallway and entered into Resident 18's room. The two residents shouted at each other and Resident 18 hit Resident 4 on the head, causing skin tears. She indicated Resident 4 was more cognitively intact than Resident 18.On 9/24/25 at 10:12 a.m., Resident 18's clinical record was reviewed. The diagnoses included, but were not limited to bipolar disorder, depression with psychotic features, cognitive communication deficit, adjustment disorder with depressed mood, and anxiety.An 8/15/25 quarterly MDS assessment indicated Resident 18's cognition was severely impaired.During an interview on 9/29/25 at 11:16 a.m., CNA 3 indicated the Resident 18 was not cognitively intact. On 9/23/25 at 12:30 p.m., the ADM provided the facility policy, ABUSE PREVENTION PROGRAM, dated 10/22/22, and indicated it was the policy currently being used. A review of the policy indicated, It is the policy of this facility to prevent resident abuse . mistreatment . This facility will not tolerate resident abuse or treatment by anyone including . other residents .3.1-27(a)(1)3.1-27(b)

Based on record review and interview, the facility failed to ensure an accurate assessment for 2 of 15 residents reviewed for MDS (Minimum Data Set) assessment accuracy. Antidepressants, Level II assessments, and hospice services were coded incorrectly. (Resident 39, Resident 3)Findings include: 1. On 9/25/25 at 1:42 p.m., Resident 39's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety disorder, insomnia (persistent problems falling and staying asleep), and depression. The admission Minimum Data Set (MDS) assessment, dated 9/8/25, did not indicate the resident was on an antidepressant medication and indicated the resident had not received a Preadmission Screening and Resident Review (PASRR) Level II. A review of Resident 39's medication orders indicated, the resident was taking Escitalopram (a medication used to treat depression) 20 milligrams (mg) daily. The medication was prescribed on 8/28/25 for a diagnosis of depression, and the resident had continued to take this medication. A review of the resident's documents indicated a notice of PASRR Level II Outcome, dated 9/4/25, Final Determination By: Determination Date: 9/4/25, Level II Outcome: Long Term Approval without Specialized Services. During an interview on 9/26/25 at 12:59 p.m. with the MDS Coordinator, she indicated the resident was on an antidepressant at the time of the admission MDS Assessment, dated 9/8/25. She indicated section N0415C1 Antidepressant, was marked no and it should have been marked yes. The MDS coordinator indicated the facility did not have a MDS policy, she indicated they utilized the Resident Assessment Instrument (RAI) manual to code MDS Assessments. A review of the RAI, Version 3.0 User's Manual, on 9/26/25 at 2:00 p.m., indicated .Item N0415, High-Risk Drug Classes: Use .Review the resident's medical record for documentation that any of these medications were received by the resident .during the 7-day lookback period . During an interview with the MDS coordinator on 9/26/25 at 2:57 p.m., she indicated section A1500 on admission MDS assessment, dated 9/8/25, was marked no and she indicated it should have been marked yes for PASRR Level II. On 9/26/25 at 3:00 p.m., a review of the RAI, Version 3.0 User's Manual, for section A1500 of MDS, indicated Code 1, yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID (Intellectual disability)/DD (Developmental disability) or related condition . 2. On 9/24/25 at 2:20 p.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and chronic obstructive pulmonary disease. An active physician's order with a start date of 5/22/25 indicated the resident received hospice care. A current care plan, dated of 5/22/25 indicated the resident received hospice care. The quarterly MDS assessment, dated 8/21/25, section J1400 indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. Section O0110, K1 indicated the resident did not receive hospice care. During an interview on 9/29/25 at 11:00 a.m., the MDS Coordinator indicated the resident was receiving hospice care, and the assessment was incorrectly coded on the 8/21/25 quarterly MDS assessment. 3.1-31(d)

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when a new mental health diagnosis was added for 1 of 3 residents reviewed for PASARR. (Resident 6)Finding includes:On 9/29/25 at 11:33 a.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, depression, and anxiety.The PASARR Level I, dated 2/10/25, indicated no Level II was required due to no severe mental illness. The Level 1 indicated no mental health diagnosis was known or suspected. If new changes occur or new information refuted these findings, a new screen must be submitted.Resident 6 was admitted on [DATE] with diagnoses of depression and anxiety.The clinical record lacked a new Level I screen with the diagnoses of depression and anxiety.During an interview on 9/29/25 at 11:24 a.m., the Minimum Data Set (MDS) nurse indicated a new Level I would be done when a new diagnosis or a new psychotropic medication was prescribed.During an interview on 9/29/25 at 11:43 a.m., the MDS nurse indicated Resident 6 required a new Level I completed due to new diagnoses of anxiety and depression.On 9/29/25 at 1:32 p.m., the facility provided the facility's policy, Guidelines for PASRR Process, dated 5/17/23, and indicated it was the policy currently being used by the facility. The review of the policy indicated .People (residents), who are confirmed to have ID [intellectual disability], DD [developmental disability], MI [mental illness] are evaluated to determine the need for specialized services, and appropriate placement options are reviewed .3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary intervention to promote healing of a facility acquired pressure ulcer for 1 of 3 residents reviewed for pressure ulcer. (Resident 53)Finding includes:On 9/23/25 at 12:27 p.m., Resident 53 was observed to be eating lunch in the dining room. She was observed to be wearing a yellow sock on her left foot with her left foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair. On 9/23/25 at 2:29 p.m., Resident 53 was observed to be sitting in the hallway. She was observed to be wearing a yellow sock on her left foot with her left foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair.On 9/24/25 at 9:43 a.m., Resident 53 was observed to be sitting in her wheelchair in the dining room. She was observed to be wearing a yellow sock on her left foot with her foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair.On 9/24/25 at 1:36 p.m., Resident 53 was observed to be sitting in her wheelchair in the dining room. She was observed to be wearing a yellow sock on her left foot with her foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair.On 9/25/25 at 9:40 a.m., Resident 53 was observed to be sitting in her wheelchair in the dining room. She was observed to be wearing a yellow sock on her left foot with her foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair.On 9/25/25 at 2:40 p.m., Resident 53 was observed to be sitting in her wheelchair in the dining room. She was observed to be wearing a yellow sock on her left foot with her foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair.On 9/26/25 at 10:36 a.m., Resident 53's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), unstageable pressure ulcer of the left heel, and vascular dementia.The Braden Scale for Predicting Pressure Score Risk indicated the following:-On 4/30/25 at 8:26 p.m., Resident 53 was a low risk for pressure ulcer.-On 7/30/25 at 10:00 a.m., Resident 53 was a low risk for pressure ulcer.The quarterly Minimum Data Set (MDS) assessment, dated 6/11/25, indicated Resident 53 had severe cognitive impairment and was at risk for pressure ulcers.The care plan, dated 7/29/25, indicated Resident 53 had an unstageable wound to her left heel. The interventions were offloading boots while in bed as tolerated. She kicked off heel boots while in bed at times. The care plan lacked documentation of what interventions were in place to help relieve pressure from left heel while in the wheelchair.The Nurse Practitioner (NP) progress note, dated 9/3/25 at 12:49 p.m., indicated Resident 53 had an unstageable pressure ulcer to left heel. The wound was stable. The size was 2.5 cm (centimeters) x 3 cm x 0.1 cm deep. The current treatment plan was to offload the wound bed.The Weekly Wound Evaluation, dated on 9/3/25 at 1:08 p.m., Resident 53 had a suspected deep tissue injury (damage to the soft tissue under the skin caused by pressure) to left heel. The measurements were length 2.5 centimeters (cm), width 3.0 cm, and depth 0.1 cm. The area was identified on 7/23/25. The wound was pink. The current treatment was to clean wound every day with wound cleanser, apply medical grad honey and apply bordered foam dressing. The current preventative interventions were wheelchair cushion, nutritional supplements, and heel boots.The Weekly Wound Evaluation, dated on 9/10/25 at 10:40 a.m., Resident 53 had a suspected deep tissue injury to left heel. The measurements were length 2.5 cm, width 3.0 cm, and depth 0.1 cm. The area was identified on 7/23/25. The wound was pink. The current treatment was to clean wound every day with Dakin's solution (wound cleanser), apply medical grad honey and cover with Dakin's moisten fluff gauze and bordered foam dressing. The current preventative interventions were wheelchair cushion, nutritional supplements, and heel boots.The NP progress note dated, on 9/10/25 at 1:34 p.m., Resident 53 had an unstageable pressure ulcer to left heel. The wound was stable. The size was 2.5 cm x 3 cm x 0.1 depth. The current treatment plan was to offload the wound bed.The NP progress note dated, on 9/17/25 at 7:49 a.m., Resident 53 had an unstageable pressure ulcer to left heel. The wound was stable. The size was 2.2 cm x 2.8 cm x 0.1 depth. The current treatment plan was to offload the wound bed.The Weekly Wound Evaluation, dated on 9/17/25 at 10:22 a.m., Resident 53 had a suspected deep tissue injury to left heel. The measurements were length 2.2 cm, width 2.8 cm, and depth 0.1 cm. The area was identified on 7/23/25. The wound was pink. The current treatment was to clean wound every day with betadine (wound cleanser), apply betadine soaked gauze to wound and wrap with kerlix and secure with tape. The current preventative interventions were wheelchair cushion, nutritional supplements, and heel boots.The NP progress note dated, on 9/24/25 at 2:36 p.m., indicated the previous documentation was reviewed. Resident was seen for ongoing assessment and management of the left heel pressure ulcer. Significant slough overlying wound base. Resident tolerated sharp debridement. Depth increased to wound following sharp debridement today. Able to identify bone underlying slough with use of cotton tipped applicator. Wound staging updated to stage 4 pressure ulcer from unstageable. The wound was not listed as worsening as this was an expected progression with removal of slough and better evaluation of wound base. Wound care recommendation for hydrogel for ongoing autolytic debridement. The Weekly Wound Evaluation, dated on 9/24/25 at 3:03 p.m., Resident 53 had a suspected deep tissue injury to left heel. The measurements were length 2.0 cm, width 2.8 cm, and depth 0.1 cm. The area was identified on 7/23/25. The wound was pink. The current treatment was to clean wound every day with wound cleanser, apply hydrogel (wound dressing) to wound and pack with lightly with moistened normal saline gauze, and wrap with kerlix and secure with tape. The current preventative interventions were wheelchair cushion, nutritional supplements, and heel boots.The Physician Order indicated to cleanse the left heel with wound cleanser and pat dry, apply hydrogel to wound, packed lightly with moistened normal saline gauze, wrap with rolled gauze, and secure with tape. (Start date 9/24/25)The clinical record lacked documentation of how to ensure Resident 53 had pressure relieving to her pressure ulcer on her left heel while up in her wheelchair.During an interview on 9/26/25 at 10:13 a.m., CNA 1 indicated Resident 53 had a pressure ulcer to her left heel. She indicated while in bed Resident 53 had a wedge to keep heels off the mattress. While in the chair, Resident 53 was to keep her feet off the floor. If Resident 53's feet were on the floor, they would use wheelchair pedals and float her heels while she was in the wheelchair. During an interview on 9/26/25 at 10:19 a.m., Qualified Medication Aide (QMA) 1 indicated while Resident 53 was in bed, her heels were floated. She was unsure if Resident 53 was to float heels while in wheelchair.During an observation on 9/26/25 at 11:43 a.m., the Director of Nursing (DON) removed the dressing off Resident 53's left foot. A quarter-sized pressure ulcer was observed on the bottom of her left heel.On 9/29/25 at 1:32 p.m., the Administrator provided the facility policy, Guidelines for Prevention/Treatment of Pressure Injuries, dated 10/9/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated .Encourage the use of.fabrics/appropriate bed surfaces - mattresses/positioning devices.3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received the appropriate care to prevent urinary tract infections for 1 of 2 residents reviewed for urinary tract infections. (Resident 9)Findings include: On 9/26/25 at 11:31 a.m., Resident 9 was observed in the activity room with his urinary catheter bag inside of a concealed bag, which was touching the ground, below his reclining wheelchair.On 9/26/25 at 2:40 p.m., Resident 9 was observed in the activity room with his urinary catheter bag inside of a concealed bag, which was touching the ground, below his reclining wheelchair.On 9/24/25 at 10:39 a.m., Resident 9's clinical record was reviewed. The diagnoses included, but were not limited to Alzheimer's disease, type 2 diabetes mellitus, benign prostatic hyperplasia with lower urinary tract symptoms, dementia, obstructive and reflexive uropathy (a condition where urine flow is blocked in the urinary tract, leading to a buildup of urine and potential damage to the kidneys). A care plan, initiated 3/17/23, indicated the resident had a supra pubic catheter placed on 6/20/25 and had a diagnosis of BPH with obstructive uropathy. An intervention included, Monitor position of drainage bag .A 9/11/25 UTI (Urinary Tract Infection) note indicated the resident was diagnosed with a UTI, prescribed an antibiotic until 10/11/25, and had cloudy, foul-smelling urine.During an interview on 9/26/25 at 2:00 p.m., the clinical nurse consultant indicated there was not an infection control issue with the concealment bag being on the ground. However, she indicated it did not look pretty, and she was going to reposition the bag so it was not on the ground.On 9/29/25 at 1:32 p.m., the Administrator provided the facility policy, GUIDELINES FOR INDWELLING FOLEY CATHETER CARE, dated 10/16/24, and indicated it was the policy currently being used. A review of the policy did not indicate guidelines for urinary catheter bag placement in regard to touching the ground. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the daily census report had the actual hours worked by staff for 7 of 7 days of daily posted nurse staffing reviewed. Finding includes:On 9/23/25 at 11:30 a.m., the daily census report, dated 9/23/25, indicated no actual hours worked.On 9/29/25 at 12:23 p.m., the Administrator (ADM) presented the daily census report, dated 9/23/25 through 9/29/25. The daily census report lacked documentation of actual hours worked.During an interview on 9/29/25 at 12:58 p.m., the ADM indicated the daily census report posted lacked documentation of the actual hours worked.On 9/29/25 at 1:32 p.m., the ADM provided the facility's policy, Staffing Posting Requirement, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .It is the policy of the facility, in cooperation with Medicare/Medicaid Services (CMS), to comply with the requirement of daily posting staff in the facility .

Based on observation, interview, and record review the facility failed to ensure an effective pest control program was in place when ants were observed inside a residents dresser drawer for 1 of 1 random observations. (Resident B) Findings include: On 6/30/25 at 12:19 p.m., observed seven ants crawling on the outside of a dresser drawer. The dresser drawer had been opened approximately 3 inches. Observed five ants crawling inside the dresser drawer. At that time, Resident B indicated the ants were in her room all the time. The ants had been found in Resident B's bed in the past. The clinical record for Resident B was reviewed on 6/30/25 at 12:34 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, personality disorder, and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident B was cognitively intact. On 6/30/25 at 12:44 p.m., the Administrator provided a copy of an undated facility policy, titled Pest Control Policy, and indicated this was the current policy used by the facility. A review of the policy indicated the policy is to ensure a pest free environment within the facility. This citation relates to Complaint IN00462508. 3.1-19(f)(4)

A. Based on interview and record review, the facility failed to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a resident sustaining fractures of the wrist and hand and hospitalization for decreased mobility in lower extremities. (Resident B) B. Based on interview and record review, the facility failed to ensure a resident with an assessed behavior of wandering and a high risk of elopement was provided treatment and services to prevent an elopement which resulted in the resident going through an unlocked door and getting outside without staff knowledge for 1 of 3 residents reviewed for elopement. (Resident C) Findings include: A1. On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, osteoporosis (a condition where bones become weak and brittle), osteoarthritis (occurs when flexible tissue at the ends of bones wears down), and history of a healed traumatic fracture. A hospital history and physical, dated 3/6/25 at 7:27 p.m., indicated Resident B had a diagnosis of osteoporosis and compression fracture from a fall in February 2025. Documentation indicated resident had fall precautions. A physician's order for Resident B, dated 3/13/25, indicated up ad lib (able to move and mobilize freely) with assistance. The baseline care plan for Resident B, dated 3/13/25, lacked documentation of resident being at high risk for falls or interventions to prevent falls. The Admission MDS (Minimum Data Set) assessment, dated 3/18/25, indicated the resident had moderately impaired cognition, had history of falls on admission and had falls since admission. A Progress Note, dated 3/13/25 at 10:15 p.m., indicated the resident slid off her bed while attempting to stand. The fall was witnessed and an assessment was completed with no injuries or reports of pain. The physician and family were notified. A Fall Risk Assessment, dated 3/13/25 at 10:26 p.m., indicated Resident B was assessed as high fall risk due to ambulation, elimination, gait and balance. A Progress Note, dated 3/14/25 at 2:42 p.m., indicated an IDT (interdisciplinary team) Fall follow up, indicated the resident slid off the bed while attempting to get up. The resident was assessed and not observed to be injured. The care plan was reviewed and updated and a new intervention for a scoop mattress was added. A Progress Note, dated 3/23/25 at 3:00 p.m., indicated the resident had an unwitnessed fall and complained of left arm pain. The on-call physician was contacted and new orders were received as follows: x-ray of left extremity (hand, wrist and elbow), fall precautions, assess pain, monitor neurological checks and notify a clinician of any change in condition. The x-ray report for Resident B, dated 3/23/25 at 8:04 p.m., indicated the following the left hand demonstrated an oblique fracture (break that occurs at an angle across the bone's length) of the midshaft of the fourth metacarpal (a break in the middle of the bone in the hand that connects to the ring finger). There was an acute fracture of the torus variety (causes one side of the bone to bend, but does not actually break through the entire bone) in the distal left radius (the lower end of the radius bone in the forearm, located nearest the wrist). No other fractures are noted. A Progress Note, dated 3/23/25 at 10:30 p.m., indicated the physician was notified of x-ray results. The clinical record lacked documentation of any new orders or interventions after x-ray results were received. A Progress Note, dated 3/24/25 at 3:30 a.m., indicated the resident was assisted to the restroom by CNA 1. The resident was incontinent and slipped on the wet floor. CNA 1 lowered the resident to floor and called for assistance. LPN 4 went to the resident's room to assist CNA 1. The resident was unable to stand from a seated position and they placed a sheet under her and transferred her back to bed. The resident had no complaints of pain and neurological checks were with in normal limits. A Fall Risk Assessment, dated 3/24/25 at 4:27 a.m., indicated Resident B was assessed as a high fall risk due to history of falls, ambulation, elimination, gate and balance. On 3/24/25 at 3:40 a.m., a Change in Condition Summary was sent to the provider due to the fall. The summary indicated the resident had weakness in bilateral lower extremities, was unable to stand, and recommend a physical therapy evaluation. The primary care feedback indicated that there were no new interventions, testing, or recommendations applicable. On 3/24/25 at 8:33 a.m., a Change in Condition Summary was sent to the provider due to altered mental status and new neurological signs. The provider recommended the resident be sent to the emergency room . On 3/24/25 at 10:09 a.m., a late entry nursing note indicated, at 7:30 a.m., LPN 5 entered resident's room and noticed the resident was confused, had slurred speech and could not open her right eye all the way. Neurological checks were completed and the resident could not feel or move her legs. The resident complained of abdominal and low back pain. Emergency Medical Services were called and resident was transferred to the emergency room . The clinical record lacked documentation of an IDT note after Resident B's falls on 3/23/35 and 3/24/25. During an interview on 4/15/25 at 11:57 a.m., the DON indicated that resident was admitted to the facility due to a urinary tract infection and history of spinal injury from a previous fall. The DON indicated that Resident B was walking with a CNA on 3/24/25 when her legs became weak and the resident was lowered to the floor. The DON indicated that the resident was unable to stand, so the staff placed a sheet under Resident B to take her back to bed. The DON indicated they did not send the resident to the hospital due to she was lowered to the floor, her neurological checks were normal and she did not complain of pain. The DON indicated that the resident was now paralyzed. During an interview on 4/15/25 at 2:33 p.m., CNA 1 indicated she had assisted Resident B to the restroom on 3/24/25. CNA 1 indicated that Resident B had tingling and numbness occasionally in her legs. CNA 1 indicated she asked the resident if she was experiencing any tingling or numbness and the resident denied having any. CNA 1 indicated that Resident B ambulated with a walker. CNA 1 indicated while walking Resident B to the restroom, the resident complained of left leg pain and tingling, CNA 1 indicated she had resident sit on the seat of her walker and pushed her to the restroom. CNA 1 indicated the resident was able to stand and pivot to the commode but started to urinate while standing. CNA 1 indicated the resident's right foot was sliding and she lowered the resident to the floor. CNA 1 indicated she called for assistance and LPN 4 came to assist her, she indicated that they were unable to get a mechanical lift into the restroom, so they placed a sheet under Resident B and carried her back to bed. During an interview on 4/16/25 at 9:52 a.m., LPN 5 indicated she had received report on 3/24/25 at approximately 6:30 a.m. LPN 5 indicated it was reported that Resident B had a fall during the night. LPN 5 indicated that when LPN 5 went to Resident B's room to check her blood sugar LPN 5 noticed the resident was confused and not acting like herself. LPN 5 indicated the resident complained of low back pain and stomach pain. LPN 5 indicated the resident was unable to move her legs and could not feel the nurse touching them. LPN 5 indicated she called 911 and the ambulance arrived at approximately 8:00 a.m. During an interview on 4/16/25 at 10:58 a.m., LPN 2 indicated she had worked on 3/23/25 when Resident B had slid off her bed. LPN 2 indicated that Resident B complained of wrist and hand pain after the fall. LPN 2 indicated she called the provider on call and received an order for an x-ray. She indicated at approximately 10:30 p.m., LPN 2 notified the family, the DON and Executive Director (ED) of the results. LPN 2 indicated she placed the x-ray results in the provider binder at the nurses station. LPN 2 indicated she did not call the provider on call with the results. LPN 2 indicated she was unsure when the medical providers looked at the binder because she only worked Saturdays and Sundays. During an interview on 4/16/25 at 2:05 p.m., the ED indicated there was no IDT note or root cause analysis completed after falls on 3/23/25 or 3/24/25, for Resident B. On 4/15/25 at 12:53 p.m., the DON provided the facility's policy Guidelines for Incidents/Accidents/Falls, dated 6/30/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately .a written report will be entered into Risk Management .information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible .6. The incident/accident report will be completed as soon as information is obtained .11. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall .15. Based on results of the incident/accident/fall, the resident's care plan will be addressed .with appropriate interventions in place . 35318 B1. Resident C's clinical record was reviewed on 4/15/25 at 12:38 p.m. The diagnosis included, but was not limited to, Lewy Bodies dementia. The Elopement Risk Review form, dated 2/19/25, for Resident C indicated the resident was assessed as being a high risk for elopement. A care plan, initiated on 10/2/23, for Resident C indicated, .Focus: Resident is at risk for wandering . Goal: Resident will have no injuries related to wandering daily . Interventions: Document any wandering activity and interventions attempted . Notify and update MD/NP [medical doctor/nurse practitioner] and family of any changes in wandering activity . Provide resident with food, drink, offer toileting, walk with resident and offer other activities . A review of a State Reportable on Resident C indicated, on 3/26/25 at 11:01 a.m., staff observed the resident in a wheelchair immediately outside of the exit door. Staff immediately accompanied the resident inside the facility without incident. Resident was wearing appropriate clothing and footwear. The follow up on 4/4/25 indicated, the exit door mag lock failed and the resident was able to exit. A review of nursing progress notes on Resident C indicated, on 3/26/25 at 11:34 a.m., the resident was unable to be evaluated by the skin and wound team due to resident being out of the room and was unable to be located. The progress notes lacked documentation of an incident where Resident C was found outside of the exit door on 3/26/25. During an interview on 4/15/25 at 2:30 p.m., the DON indicated she was on vacation when Resident C eloped but she believed it to be in the daytime. He was in a wheelchair and rolled down the unit that was closed and not used for residents. The lock was not working and he was able to get out. She was unsure how long he had been outside but believed the weather to be nice that day. The facility did do an incident report but did not make a note in the nursing progress notes. During an interview on 4/16/25 at 9:30 a.m., Physical Therapist 1 indicated she found Resident C outside the door in the back on the hallway with no residents sometime before noon on 3/26/25. The wound care team had been looking for him and couldn't find him. She went looking and decided to try the back door on the closed unit. He was sitting outside unharmed. She was unsure how long he had been outside. During a tour on 4/16/25 at 10:26 a.m., the closed unit was observed to have two closed doors with a sign indicating the unit was closed. A door at the end of the hallway was observed to lead out to a porch with a ramp directly behind the backside of the smoking shack used by residents. No residents or staff were observed to be in the area at the time. During an interview on 4/16/25 at 11:02 a.m., the Administrator indicated she was unable to locate nursing progress notes related to Resident C's elopement on 3/26/25. During an interview on 4/16/25 at 11:25 a.m., LPN 1 indicated she had checked Resident C's blood sugar at approximately 9:00 a.m. on 3/26/25, and would have checked it again around 11:00 or 11:30 a.m., that same morning. She did not remember seeing him between those times. During an interview on 4/16/25 at 11:34 a.m., LPN 3 indicated she had been telling the facility for quite some time the back door lock was not working and she had seen Resident C attempting to get through the doors to the closed unit many times. He had indicated to her, I'm an escapee you know. On 4/16/25 at 11:11 a.m., the Administrator provided the policy, Policy and Procedure for Personal Safety Devices for Resident at Risk of Elopement, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs . 6. All . exit doors alarms will be tested every shift to verify that each device and door alarm are functioning properly . This citation relates to Complaints IN00456323 and IN00456968. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the physician was notified of the x-ray results for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. Resident B's progress notes indicated the following: - On 3/23/25 at 3:00 p.m., Resident B had tried to get up out of the bed to the use the bathroom. She leaned on the bedside table and fell to the floor. She had left arm pain. The NP (nurse practitioner) was notified. New orders were received for x-ray of left arm and to notify the clinician of any change in condition. - On 3/23/25 at 10:30 p.m., the physician was notified of the x-ray results. The documentation lacked how the physician was notified. During an interview on 4/16/25 at 10:58 a.m., LPN 2 indicated she worked on 3/23/25 when Resident B fell . She notified the NP of Resident B's complaint of left arm. The NP ordered an x-ray. When the x-ray results came in around 10:30 p.m., she placed the results in the physician binder. She did not call the physician. She only worked weekends and did not know when the physician would see the x-ray results in the binder. On 4/16/25 at 2:05 p.m., the Administrator provided the facility's policy, Change in Resident's Condition or Status, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. The nurse will notify the resident's attending physician when: An abnormal x-ray result or a worsened x-ray result of a previously know injury or disease process . This citation relates to Complaint IN00456968. 3.1-5(a)(1)

Based on interview and record review, the facility failed to ensure the baseline care plan was implemented for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. The hospital History and Physical note, dated 3/6/25 at 7:27 p.m., indicated Resident B had osteoporosis and compression fracture of the lumbar and thoracic spine. Resident B was on fall precautions. The Baseline Care Plan, dated 3/13/25, lacked documentation of resident having a history of falls or resident's signature. The Fall Risk Review indicated the following: - On 3/13/25 at 10:26 p.m., the review indicated a high risk for falls. - On 3/24/25 at 4:27 a.m., the review indicated high risk for falls. During an interview on 4/15/25 at 11:57 a.m., the Director of Nursing (DON) indicated she presented all Resident B's care plans. At that time, a review of the care plans lacked a high risk for falls care plan. On 4/16/25 at 2:05 p.m., the Administrator provided the facility's policy, Baseline Care Plan Assessment/Comprehensive Care Plans, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions .2. Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT [Interdisciplinary Team] team at the Morning Meeting/CQI (Clinical Quality Indicator) Meeting. The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan . This citation relates to Complaint IN00456968.

Based on interview and record review, the facility failed to notify the resident's representative of a significant change in the resident's physical status for 1 of 3 residents reviewed for notification of changes. (Resident B) Findings include: On 1/22/25 at 1:20 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, atherosclerotic heart disease and dementia. A nursing progress note, dated 9/5/24 at 10:43 p.m., indicated a pressure ulcer was newly discovered on the resident's coccyx, and a telephone call was placed in an attempt to contact the resident's family representative. Contact was not made with the representative. No further attempts to contact the resident's family representative were documented regarding the discovery of the wound. A wound assessment report, dated 9/11/24, indicated the resident had an unstageable pressure ulcer on the coccyx measuring 5 cm (centimeters) long and 2 cm wide. The wound was acquired during the resident's stay at the facility and discovered on 9/5/24. During an interview on 1/23/25 at 10:30 a.m., the resident's representative indicated she had not been contacted by the facility regarding the 9/5/24 discovery of a pressure ulcer on the resident's coccyx. During a visit with the resident on 9/14/24, a staff member mentioned the wound on the resident's coccyx. This was the first she was notified of the wound. Communication from the facility was inconsistent during the resident's stay at the facility. During an interview on 1/23/25 at 10:50 a.m., the Director of Nursing indicated residents' family and representatives were contacted via telephone regarding change of conditions. If the family member or representative did not answer the phone, a message was left requesting a return call. No further follow-up calls were made unless the resident was being transferred to the hospital. During an interview on 1/23/25 at 11:10 a.m., the facility Administrator indicated if there was a change in condition of a resident, a family member or representative was called. If the family member or representative was not reached and had not returned the call by the end of that shift, staff should have attempted a follow-up call. On 1/23/25 at 10:10 a.m., the facility Administrator provided the Change in Resident's Condition or Status policy, undated, and indicated this was the policy used by the facility. A review of the policy indicated the nurse would notify the resident's representative within 24 hours when there was a significant change in the resident's physical status. This citation relates to Complaint IN00451389. 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure resident's grievances were acted upon and promptly resolved for residents who had food concerns for 5 of 5 residents meals reviewed. (Resident B, Resident C, Resident D, Resident E, and Resident F). Findings include: On 12/27/24 at 11:56 a.m., Resident D indicated they had not been receiving desserts or any fruit. During the Resident Council Meeting, resident's had complained about not getting any desserts or any fruit. He did not receive any fruit cocktail at lunch on that day (12/27/24). At that time, Resident D's meal tray was observed not to have any fruit cocktail. On 12/27/24 at 12:00 p.m., Resident B was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:03 p.m., Resident C was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:10 p.m., Resident E was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:15 p.m., Resident F was observed to be in the dining room. She was observed not to have any fruit cocktail. During an interview on 12/27/24 at 12:20 p.m., The Dietary Manager indicated the fruit cocktail was in the refrigerator and they had not given it with the lunch tray. On 12/27/24 at 12:30 p.m., the Director of Nursing (DON) provided the Resident Council Meeting Minutes. The minutes indicated the following: - On 11/20/24 at 2:15 p.m., the new business included, but was not limited to, not getting fruit or desserts with meals. During an interview on 12/27/24 at 12:42 p.m., Resident E was observed to be sitting in the dining room and indicated he was not offered any fruit cocktail. During an interview on 12/27/24 at 12:42 p.m., Resident F was observed to be sitting in the dining room, she indicated she was not offered any fruit cocktail. During an interview on 12/27/24 at 12:44 p.m., Resident B was observed to be sitting in the dining room with his lunch on the table. He was observed not to have any fruit cocktail. During an interview on 12/27/24 at 1:23 p.m., Resident D indicated he was not offered any fruit cocktail. On 12/30/24 at 2:30 p.m., the DON provided the facility's policy, I Would Like to Know, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated 8. When the root cause is identified, corrective action can be taken to resolve the issue as much to the satisfaction of the resident or the resident's representative as possible . This citation relates to Complaints IN00449830, IN00449840, and IN00450088. 3.1-7(a)(2)

Based on interview and record review, the facility failed to ensure residents with orders for house shakes were administered for 9 of 9 residents who had orders for health shakes. (Resident H, Resident J, Resident K, Resident L, Resident M, Resident B, Resident N, Resident O, Resident P) Findings include: During an interview on 12/30/24 at 11:10 a.m., the Dietary Manager (DM) indicated the facility was out of house shakes. During an interview on 12/30/24 at 11:56 a.m., the DM indicated the facility ran out of house shakes sometime over the weekend. On 12/30/24 at 1:00 p.m., the Director of Nursing (DON) presented an Order Listing Report, dated 12/30/24 at 12:54 p.m. The list indicated the following: - Resident H had an order for house shakes with meals (start date 5/21/24). - Resident J had an order for house shake three times a day (start date 11/1/24). - Resident K had an order for house shake one time a day for supplement/wound healing (start date 8/20/24). - Resident L had an order for house shake one time a day for wound healing (start date 8/20/24). - Resident M had an order for house shake two times a day (start date 11/20/24). - Resident B had an order for house shake one time a day (start date 10/29/24). - Resident N had an order for house shake with meals (start date 9/20/24). - Resident O had an order for house shake two times a day (start date 11/26/24). - Resident P had an order for house shakes with meals for weight loss (start date 10/8/24). During an interview on 12/30/23 at 1:50 p.m., the Administrator (ADM) indicated the facility ran out of health shakes on Saturday evening. They did not have enough health shakes for Saturday at bed time, all day Sunday, and until lunch on Monday. On 12/30/24 at 2:47 p.m., the ADM provided the facility's policy, Fortified Foods, Two Calorie Med Pass and Other Supplements/Snacks, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .7. All hours Supplements and Snacks that are given between meals will be prepared by the Dining Services Department and delivered to nursing for distribution . This citation relates to Complaints IN00449830, IN00449840, and IN00450088. 3.1-20(a)

Based on observation, interview, and record review, the facility failed to follow the menus for 2 of 2 meals observed. (Resident D, Resident B, Resident C, Resident E, Resident F) Findings include: During an tour of the kitchen on 12/27/24 at 10:30 a.m., the Dietary Manager indicated the lunch menu was fried chicken, mashed potatoes, baked beans, and fruit cocktail. On 12/27/24 at 11:56 a.m., Resident D indicated they had not been receiving desserts or any fruit. During the resident council meeting, resident's had complained about not getting any desserts or any fruit. Resident D indicated he did not receive any fruit cocktail at lunch. At that time, Resident D's lunch was observed. Resident D was observed not to have any fruit cocktail. On 12/27/24 at 12:00 p.m., Resident B was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:03 p.m., Resident C was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:10 p.m., Resident E was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:15 p.m., Resident F was observed to be in the dining room. She was observed not to have any fruit cocktail. During an interview on 12/27/24 at 12:20 p.m., the DM indicated the fruit cocktail was in the refrigerator and they had not given it with the lunch tray. On 12/27/24 at 12:30 p.m., the Director of Nursing (DON) provided the Resident Council Meeting Minutes, dated 11/20/24 at 2:15 p.m. The new business indicated the residents were not getting any fruit or desserts with meals. During an interview on 12/27/24 at 12:42 p.m., Resident E was observed to be sitting in the dining room and he indicated he was not offered any fruit cocktail. During an interview on 12/27/24 at 12:42 p.m., Resident F was observed to be sitting in the dining room and she indicated she was not offered any fruit cocktail. During an interview on 12/27/24 at 12:44 p.m., Resident B was observed to be sitting in the dining room with his lunch on the table. He was observed not to have any fruit cocktail. During an interview on 12/27/24 at 1:23 p.m., Resident D indicated he was not offered any fruit cocktail. On 12/30/24 at 11:40 a.m., the menu posted behind the receptionist indicated lunch was nachos, rice, and Dutch apple pie. On 12/30/24 at 11:54 a.m., Resident C was observed to be in the dining room. His lunch was baked beans, rice topped with a brown substance and cheese on top and a dish with marshmallows. No apple pie was observed. On 12/30/24 at 11:55 a.m., Resident D was observed to be in the dining room. His lunch was nachos topped with a brown substance and cheese on top and a dish with marshmallows. No apple pie was observed. On 12/30/24 at 12:10 p.m., Resident B was observed to be in the dining room. His lunch was rice topped with brown substance and cheese on top, baked beans, and a dish with marshmallows. No apple pie was observed. On 12/30/24 at 12:20 p.m., the Activity Director (AD) presented the Resident Council Meeting Minutes, dated 12/27/24 at 2:15 p.m. The old business indicated not getting fruit or desserts with meals. The new business indicated no dessert or fruit with meals. At that time, the AD indicated the residents at Resident Council were still not getting their desserts or fruit with meals. The cook provided a hand written menu for 12/30/24. The lunch menu was nachos, baked beans, rice, and Dutch apple pie. On 12/30/24 at 2:34 p.m., the DON presented the dietician approved lunch menu for 12/27/24 and 12/30/24. The 12/27/24 lunch menu indicated it was approved on 12/20/24 and was grilled hot dog on bun, buttered spinach, cheesy hash brown potatoes, and pineapple upside down cake. The 12/30/24 lunch menu indicated it was approved on 12/20/24 and was country chicken and dumplings, glazed carrots, and diced pears. On 12/30/24 at 2:33 p.m., the DON provided the facility's policy, Menu Substitutions, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated staff may choose any food within the same list to substitute for the unavailable food . This citation relates to Complaints IN00449830, IN00449840, and IN00450088. 3.1-20(i)(4)

Based on interview and record review, the facility failed to notify physician of a resident's change in condition for 1 of 3 residents reviewed for medication administration. The physician was not notified of resident refusal to take medication or increased behaviors. (Resident C) Findings include: On 10/3/24 at 10:34 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder, paranoid personality disorder, bipolar, and insomnia. A review of the resident's physician's orders indicated the following: - On 7/29/24 the resident was prescribed divalproex (an anticonvulsant medication indicated for the treatment of the manic episodes associated with bipolar disorder) extended release (ER) 1500 milligrams (mg) at bedtime for bipolar disorder. The medication was discontinued on 8/18/24. - On 8/26/24 the resident was prescribed divalproex sodium ER 1500 mg at bedtime for bipolar disorder. The medication was discontinued on 9/18/24. - On 9/27/24 the resident was prescribed divalproex sodium ER 500 mg three times a day (10:00 a.m., 2:00 p.m., and 8:00 p.m.) for bipolar disorder. A review of the progress notes indicated the following: - On 8/1/24 at 9:35 p.m., the resident refused his medications. A representative for the resident was notified and they informed the staff that he had done this before and did not know what caused it. - On 8/4/24 at 12:26 p.m., the resident demanded ice-cream and was reminded by the staff they did not have any. He became agitated, was rude to staff, and caused a disruption. - On 8/4/24 at 1:21 p.m., the resident demanded to go outside to smoke while the CNA's provided care to other residents. The CNA's told him he would need to wait while staff provided care to other residents. The resident became highly agitated, screamed, slammed the table, stomped down the hall, threatened staff, and threatened to call the police to press charges. - On 8/10/24 at 3:30 a.m., the resident was agitated, yelling, talking and laughing to himself at the same time. The staff approached him, but they were unable to understand what he murmured to himself. He was observed to take pictures of the staff at the nurses' station while he laughed hysterically. He remained awake all night. - On 8/12/24 at 12:46 a.m., when the resident was in his bed, he screamed as loud as he could, urinated all over his bed and the floor, and verbally abused two CNA's while they tried to clean him up. He demanded money from the staff and for them to get him food that was not available at the facility. He was cleaned up, encouraged to sit by the nurses' station, and given a drink and a snack. The interventions did not work. He continued to be verbally aggressive with the staff and mumbled obscenities to himself about the staff and services provided. - On 8/13/24 at 5:34 a.m., the resident had been yelling, teasing, and taunting staff all night. He requested cigarettes every hour and stated it was his behavior to be loud. The resident's behavior got worse at 3:00 a.m., with continued yelling, which woke up and upset the other residents. He threatened staff by saying he would cut their heads off. He was seen talking to himself, yelling, and slamming his bedroom door. He waited at the nurses' station to eat breakfast and leave the building. - On 8/15/24 at 7:08 p.m., the resident was overhead telling the Qualified Medication Aide (QMA) he would not take his Depakote (divalproex sodium) and he had not taken it for four days. - On 8/15/24 at 7:24 p.m., another resident's family member went up to the nurse and told them the resident walked across the hall into their room with just a sweatshirt on and nothing below (the sweatshirt). The resident shouted to the family he needed a brief and demanded they get him one. When the resident left the room he vehemently shouted curse words indicating he needed a brief. When he was redirected by staff he continued to use curse words and stated the staff needed to do their jobs. - On 8/15/24 at 11:39 p.m., the resident cussed and yelled at the staff for most of the evening. The resident believed a cup at the nurses' station was his and demanded the staff to get it for him. When staff told him it was staff member's personal cup and not his coffee, he continued to yell and curse for 15 minutes. - On 8/16/24 at 11:51 a.m., the Social Services Director (SSD) spoke with the Veterans Administration (VA) social worker who suggested the staff send the resident to VA psychiatry for stabilization. The resident had a history of psychotic behavior and would continue to ramp up. Per the VA social worker, he was manic, psychotic, and needed psychiatric hospitalization . - On 8/16/24 at 1:29 p.m., the resident was picked up by an ambulance and transported to VA emergency department for manic/psychotic episodes. - On 8/26/24 at 2:35 p.m., the resident arrived back to the facility from the VA hospital. - On 9/30/24 at 10:16 a.m., the resident refused Depakote, stated he would not take it, and preferred the psychiatric provider would prescribe something different. - On 10/2/24 at 10:09 a.m., the resident refused Depakote and continued to verbalize he would not take it. - On 10/2/24 at 3:06 p.m., the resident refused Depakote and stated he would not take it. - On 10/3/24 at 11:26 a.m., the resident continued to refuse Depakote. A review of the resident's EMAR (Electronic Medication Administration Record) indicated during the month of August, 2024, the resident received his divalporex medication 5 times from 8/1/24 to 8/15/24. He was sent to the VA hospital on 8/16/24. The September, 2024, EMAR indicated he received his divalporex medication 14 times from 9/1/24 to 9/26/24. On 9/27/24 his order was updated to divalporex 500 mg, 3 times a day. From 9/27/24 to 9/30/24 he received 6 out of 12 doses of medication. The resident's October, 2024, EMAR indicated he received 3 out of 8 doses of the divalporex medication. On 10/3/24 at 3:45 p.m., during an interview with the Director of Nursing (DON) she indicated she was not sure of the facility's policy in regard to residents refusal of medication. However, she believed it staff should call the physician after three refusals. On 10/3/24 at 4:54 p.m., the DON provided the facility policy, Change in Resident's Condition or Status, undated, and indicated it was the policy currently being used. A review of the policy indicated, . 1. The nurse will notify the resident's attending physician when: . The resident repeatedly refuses treatment or meds (2 times consecutively or 3 times in a 7 day period) . This citation relates to Complaint IN00444218. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of facility acquired pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. This deficient practice resulted in worsening and possible infection of an unstageable pressure ulcer and the development of a Stage III pressure ulcer. (Resident 34, Resident 5) Findings include: 1. On [DATE] at 2:06 p.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, overactive bladder, and diabetes mellitus. The Braden Scale for Predicting Pressure Ulcer, dated [DATE] at 7:52 a.m., indicated the resident was a mild risk for developing a pressure ulcer. The Annual Minimum Data Set (MDS) assessment, dated [DATE], indicated she had severe cognitive impairment; was always incontinent of urine; frequently incontinent of bowel movements; was at risk for skin breakdown; did not currently have any pressure ulcers; had no impairments for mobility with the left lower extremity; and was independent with moving in bed from left to right. A care plan, dated [DATE], indicated she required assistance with activities of daily living (ADLs) due to dementia. Her interventions were for staff to assist with transfers, toileting, and bed mobility as needed. A care plan, dated [DATE], indicated she was at risk for skin breakdown due to diagnosis of overactive bladder and decreased mobility. The interventions were Braden scale quarterly and as needed; keep resident clean and dry; pressure relieving mattress per facility policy; and skin assessment per facility policy. Wound 1: A weekly wound evaluation, dated [DATE] at 4:25 p.m., indicated a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) wound was identified on the resident's left heel and measured 2.0 centimeters (cm) length (L) X (by) 1.0 cm width (W) X less than (<) 0.1 cm depth (D). The evaluation did not include documentation to indicate a new intervention to provide pressure relief to the left heel was initiated. A nursing progress note, dated [DATE] at 4:53 p.m., indicated a wound was identified to the left heel. The note did not include documentation to indicate a new intervention to provide pressure relief to the left heel was initiated. A nursing progress note, dated [DATE] at 4:18 p.m., indicated the facility-acquired stage two pressure ulcer on the left heel deteriorated to an unstageable (the stage of the wound is unclear, the base of the wound is covered by a layer of dead tissue that may be yellow, green, gray, brown or black) pressure ulcer and measured 1.5 cm L X 1.0 cm W X < 0.1 cm depth (D). The wound base was 75 to 99 percent eschar (dead tissue). The note indicated the Nurse Practitioner (NP) recommended for staff to initiate pressure relief interventions to the left heel and bony prominence's but did not include documentation to indicate pressure relief was provided to the left heel. A Care Plan, dated [DATE], indicated the resident had an unstageable pressure injury to the left heel with interventions for diet as ordered, low air loss mattress to resident bed, skin checks weekly and as needed, and treatments as ordered. The plan did not include documentation to show interventions for pressure relief were provided to the left heel. The care plan was not developed until eight days after the pressure ulcer was found. A weekly wound evaluation, dated [DATE] at 10:23 a.m., indicated the measurements of the wound did not change. The evaluation did not include interventions to provide pressure relief to the left heel were initiated. A nursing progress note, dated [DATE] at 6:37 a.m., indicated the facility-acquired unstageable pressure injury on the left heel was stable. A weekly wound evaluation, dated [DATE] at 11:33 a.m., indicated the measurements of the wound did not change. The evaluation indicated Medihoney (a debriding dressing) should be applied to the wound. The evaluation did not include interventions to provide pressure relief to the left heel were initiated. A nursing progress note, dated [DATE] at 6:39 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left heel deteriorated and measured 2.0 cm L X 2.0 cm W X 0.1 cm D. The note indicated the NP recommended for staff to provide pressure relief to the left heel using heel boots when the resident was in bed. A weekly wound evaluation, dated [DATE] at 11:54 a.m., indicated the measurement and treatment of the wound did not change. The evaluation did not include interventions for a heel boot or pressure relief to the left heel were implemented. A nursing progress note, dated [DATE] at 6:47 a.m., indicated the facility-acquired unstageable pressure injury on the left heel deteriorated and measured 2.0 cm L X 3.0 cm W X 0.1 cm D. The wound base was 50 to 74 percent slough (dead tissue) and 50 to 74 percent eschar. The note indicated pressure relief should be provided with heel boots. The nursing progress did not indicate the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 11:37 a.m., indicated the measurement of the facility-acquired unstageable pressure injury did not change, but the treatment changed to Hydrogel (a primary dressing indicated for hydrating dry, necrotic, and sloughy wounds). A nursing progress note, dated [DATE] at 6:30 a.m., indicated the facility-acquired unstageable pressure injury on the left heel was stable and measured 1.5 cm L X 3.0 cm W X 0.1 cm D. The wound base was 100 percent eschar. The note indicated pressure relief should be provided with heel boots. The nursing progress note did not include documentation the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 11:09 a.m., indicated the facility-acquired unstageable pressure injury measured 1.5 cm L X 1.0 cm W X 0.1 cm D, but the treatment changed to Hydrogel (a primary dressing indicated for hydrating dry, necrotic, and sloughy wounds). A nursing progress note, dated [DATE] at 6:41 a.m., indicated the facility-acquired unstageable pressure injury on the left heel improved and measured 1.5 cm L X 2.5 cm W X 0.1 cm D. The wound base was 75 to 99 percent slough and 25 to 49 percent eschar. The note indicated pressure relief should be provided with heel boots. The nursing progress note did not include documentation to indicate the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 3:49 p.m., indicated the facility-acquired unstageable pressure injury measured 1.5 cm L X 2.5 cm W X 0.1 cm D. A nursing progress note, dated [DATE] at 6:34 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left heel deteriorated, exhibited signs and symptoms of infection, and measured 3.0 cm L X 2.0 cm W X 0.1 cm D. The note indicated new orders for antibiotic (ATB) therapy, pressure relief with a heel boot at all times, a wound culture, and a low air loss mattress were received. The nursing progress note indicated the wound exudate was foul smelling, 1 to 24 percent slough and 75 to 99 percent eschar. They documentation did not indicate the interventions for a heel boot or pressure relief to the left heel were implemented. A weekly wound evaluation, dated [DATE] at 3:25 p.m., indicated the facility-acquired unstageable pressure injury measured 3.0 cm L X 2.0 cm W X 0.1 cm D and the treatment changed to Santyl (a medication for debriding necrotic tissue from wounds). On [DATE] at 12:16 p.m., Resident 34 was observed at the dining room table feeding herself. She was observed to be wearing socks on both feet with her feet resting on the floor. No pressure relieving devices were observed on the resident's feet or beside the wheelchair. During an observation on [DATE] at 12:16 p.m., Resident 34 was observed sitting at a dining table without a heel boot on the left foot. The left heel was resting on the floor and observed to not have pressure relief. A nursing progress note, dated [DATE] at 6:48 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left heel deteriorated and measured 5.0 cm L X 3.5 cm W X 0.1 cm D. The wound bed was 1 to 24 percent and 75 to 99 percent eschar. The nursing progress note did not indicate the interventions for a heel boot, pressure relief to the left heel, or a low air loss (LAL) mattress were implemented. During a continuous observation on [DATE] from 10:14 a.m. through 12:16 p.m., Resident 34 was observed sitting in a wheelchair with a wound dressing on the left heel. The resident was observed to not have pressure relieving devices on or near the bilateral lower extremities. The resident was observed to unsuccessfully make significant changes in position to relieve pressure from the left buttock or heel, was observed to bear weight directly on the left heel, and was observed to use the left heel to propel the wheelchair. RN 1 and CNA 1 were observed to help the resident without providing significant position changes or devices to relieve pressure to the left buttock and heel. During an observation on [DATE] at 1:40 P.M., Resident 34 was observed lying in bed with the left heel resting on the mattress. A pressure relieving device for the heels was observed in the recliner. During an observation on [DATE] at 9:30 a.m., Resident 34 was observed seated in the wheelchair without a heel boot or pressure relief to the left heel. During an interview on [DATE] at 10:16 a.m., CNA 4 indicated Resident 34 had a decline in her ADLs. She used to ambulate per self and now required extensive assistance with toileting, transfers, and bed mobility. She had a large pressure ulcer to her left heel. Her interventions were a heels-up cushion while in bed. During an interview on [DATE] at 10:20 a.m., LPN 1 indicated Resident 34's left heel pressure ulcer was worse. During an observation, on [DATE] at 10:27 a.m., Resident 34 was observed to not have a pressure relieving device on the left heel. CNA 3 and CNA 4 were observed to transfer Resident 34 from the wheelchair to the bed and the resident was observed to bear weight on the left heel during the transfer. The bed did not have a low loss air mattress. CNA 4 indicated Resident 34 had gotten up early and had been up for a while. During an observation on [DATE] at 10:30 a.m., the NP indicate the facility-acquired unstageable pressure ulcer on the left heel looked worse, was bigger in size, was approximately the size of a golf ball, was black in the center, and the peri wound was red. During an observation on [DATE] at 10:29 a.m., Resident 34 was seated in the wheelchair without a heel boot or pressure relief to the left heel. On [DATE] at 11:36 a.m., Resident 34's clinical record was reviewed. - A weekly wound evaluation, dated [DATE] at 9:25 a.m., indicated Resident 34 had an in-house acquired unstageable pressure ulcer to left heel. The length was 5 cm L X 3.5 W cm X 0.1 cm D. During an observation on [DATE] at 2:48 p.m., Resident 34 was observed to not have a heel boot on the left heel. Resident 34 was observed to propel the wheelchair using both feet. During an interview on [DATE] at 2:48 p.m., CNA 5 indicated Resident 34 propels the wheelchair using both feet all the time. During an interview on [DATE] at 10:45 a.m., the ADON indicated that wound culture ordered on [DATE] for Resident 34 was not completed due to the facility did not have culture supplies to collect. The ADON indicated the culture tube was expired. The facility called the lab to get another culture tube and the lab indicated they would bring on next lad day. During an interview on [DATE] at 11:15 a.m., LPN 1 indicated lab was here today but did not bring a culture tubes. Wound 2: A nursing progress note, dated [DATE] at 6:34 a.m. indicated the resident developed a new, facility acquired area of skin impairment on the left buttock (Wound 2) that measured 0.7 cm L X 1.5 cm W X 0.0 cm D. The wound base was 100 percent eschar. A weekly wound evaluation, dated [DATE] at 3:37 p.m., indicated Wound 2 was a facility-acquired unstageable pressure injury and measured 0.7. cm L X 1.5 cm W X 0.0 cm D and the treatment was Santyl (a medication for debriding necrotic tissue from wounds). The evaluation did not include sufficient documentation to show interventions for pressure relief to the left buttock were implemented. The pressure relief interventions were pressure redistribution mattress and wheelchair cushion A care plan for an unstageable pressure injury on the left buttock, dated [DATE], indicated interventions to administer medications and treatments as ordered, assess, record, and monitor wound healing weekly and report improvements and declines to the physician were implemented. The plan of care did not include documentation to indicate interventions to provide pressure relief to the left buttock were implemented until [DATE] that was when the low air loss mattress was added to the care plan. The care plan was not developed until six days after the pressure injury was discovered. During an observation on [DATE] at 1:40 P.M., Resident 34 was observed lying in a supine position (on the back) on the bed with the left buttock resting on the mattress without pressure relief of low loss air mattress A nursing progress note, dated [DATE] at 6:48 a.m., indicated the NP identified the facility-acquired unstageable pressure injury on the left buttock measured 1.0 cm L X 1.8 cm W X 0.0 cm D. The note did not indicate the interventions for pressure relief to the left buttock or a low air loss (LAL) mattress were implemented. During an observation on [DATE] at 10:30 a.m., the NP indicated the facility-acquired pressure ulcer on the left buttock looked better and was about the size of a quarter. The pressure ulcer was observed to be white surrounding the area and a pink center. During an interview on [DATE] at 10:16 a.m., CNA 4 indicated Resident 34 had a decline in her ADLs. She used to ambulate per self and now required extensive assistance with toileting, transfers, and bed mobility. Resident 34 required assistance from staff to relieve pressure of her buttocks while in the wheelchair. Her interventions were to be checked every hour and half for incontinence. During an interview on [DATE] at 10:20 a.m., LPN 1 indicated Resident 34's left buttock pressure ulcer was better. On [DATE] at 11:36 a.m., Resident 34's clinical record was reviewed. A weekly wound evaluation, dated [DATE] at 9:23 a.m., indicated the facility-acquired unstageable pressure injury on the left buttock measured 1.0 cm L X 1.8 cm W X 0.0 cm D and the treatment did not change. During an interview on [DATE] at 11:37 a.m., CNA 6 indicated Resident 34 had a health decline for the last 2 weeks and had spent a lot of time in bed. Resident 34 did not have any pressure relieving devices on her feet while she was in her wheelchair. During an interview on [DATE] at 12:45 p.m., the Assistant Directors of Nursing (ADON) indicated on [DATE] they had completed skin assessments on all the residents. At that time, they found the pressure ulcer to Resident 34's left buttock. Since the pressure ulcer on left heel had gotten worse, they started the Santyl. She did not indicate any pressure relieving interventions to the left heel while the resident was in the chair or during transfers. On [DATE] at 3:45 p.m., the Director of Nursing (DON) provided the facility's policy, Guidelines for Prevention/Treatment of Pressure Injuries, dated [DATE], and indicated it was the policy being used by the facility. A review of the policy indicated, .Turn and reposition resident who are at risk for pressure injury often unless contraindicated. At least every 2 hours is recommended .Pressure ulcers/Pressure injuries are most common on the heels and sacrum 35318 2. During an interview on [DATE] at 10:15 a.m., Resident 5 indicated she had an open area on her left upper back from her bra strap. She indicated she had bought new bras, the straps were too tight, and it caused a wound on her left upper back. Resident 5's clinical record was reviewed on [DATE] at 12:04 p.m. The diagnosis included, but was not limited to, chronic diastolic congestive heart failure. The Quarterly MDS assessment, dated [DATE], indicated Resident 5 had mild cognitive impairment, rolled from left to right independently, and was at risk for developing pressure ulcers. A Weekly Skin Check, completed by the nurse, dated [DATE] at 3:58 p.m., indicated the resident did not have loss of skin integrity new or existing. A Skin and Wound Progress Note, from the Nurse Practitioner (NP), dated [DATE] at 4:58 p.m., indicated the NP identified a facility-acquired Stage III pressure ulcer on the left upper back size 0.5 cm (centimeters) x 1 cm x 0.1 cm. The NP nurse debrided necrotic tissue from the area, provided wound care, and placed a dressing. The plan for Resident 5 indicated to cleanse with normal saline, apply collagen to the base of the wound, secure with bordered gauze, and change three times per week and prn (as needed). The nursing staff were given detailed ulcer care instructions and asked to monitor the ulcer for any signs or symptoms of prolonged bleeding or debridement intolerance. Recommend ongoing pressure reduction and turning and repositioning precautions per protocol including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with staff at the time of visit. A Care Plan, initiated [DATE], indicated a pressure wound was present to resident left upper back, The interventions included, but were not limited to, treatments as ordered, pressure reducing mattress/cushion in chair, skin checks weekly and as needed. A Weekly Wound Evaluation, dated [DATE] at 4:24 p.m., indicated . Current Treatment: Collagen. Date Treatment Ordered: [DATE] . The MAR (Medication Administration Record) and the TAR (Treatment Administration Record), dated from [DATE] through [DATE] did not include documentation to show the wound treatment was administered in accordance with the NP orders until [DATE]. During an interview on [DATE] at 11:25 a.m., CNA 2 indicated Resident 5 did not have a wound on her back. During an interview on [DATE] at 11:54 a.m., LPN 2 indicated Resident 5 did not have a pressure on her back. She recently had a biopsy done which was why she had a dressing on. The clinical record lacked any indication Resident 5 had a biopsy to the left upper back. During an interview on [DATE] at 12:53 p.m., the Assistant Director of Nursing (ADON) indicated she did not know much about the wound on Resident 5's upper left back. The NP came in and found it. She did not know what it was from and thought possibly it was from the bra or the back of the chair and had been unsure what the interventions were to prevent the wound from getting worse. An email from the NP to the facility provided by the ADON on [DATE] at 3:15 p.m., was reviewed. The e-mail, dated [DATE] at 6:02 p.m., indicated, . [Resident name] . Stage III pressure injury on left upper back. See orders: Order date [DATE], cleanse with normal saline, collagen, bordered gauze, 3 times per week and as prn . During an interview, on [DATE] at 3:30 p.m., the DON indicated the treatment order for the facility-acquired unstageable pressure injury on the left upper back was received, on Friday, [DATE] at 4:22 p.m. and the receiving nurse scheduled the treatment to be administered on Monday, Wednesday, and Friday day shifts. The DON indicated the facility did not ensure the treatment was initiated between [DATE] and [DATE]. Active physician orders, dated [DATE] at 9:38 a.m., for Resident 5 indicated . Left upper back: cleanse with normal saline. Apply collagen to wound bed only. Cover with bordered gauze every day shift every Monday, Wednesday, Friday for wound healing . The order date was [DATE] and the start date was [DATE]. During an interview on [DATE] at 10:17 a.m., the NP indicated she found a Stage III pressure ulcer on Resident 5's left upper back, on [DATE], while performing rounds with LPN 3. The NP indicated a verbal order was given to LPN 3 and instructions were provided to LPN 3 for the care of the Stage III pressure ulcer. The NP sent an email with written orders in the evening of [DATE], for Resident 5's wound care treatment to the upper left back. The NP did not send anything on [DATE], as the DON indicated. The facility was responsible for inputting the information from the email into their system so orders can be started. During an interview on [DATE] at 10:42 a.m., LPN 3 indicated she rounded with the NP on [DATE], when the Stage III wound was found on Resident 5's upper left back. The NP showed her how to do the dressing change and gave her a verbal order. The NP sent an email later that evening, but she was not sure what time she received it. The facility was responsible for putting the order in the computer when the e-mail comes. She was not sure why the order said [DATE] at 4:22 p.m. During an interview on [DATE] at 11:54 a.m., the ADON and Minimum Data Set (MDS) Coordinator indicated the facility did not do an IDT meeting nor a Root Cause Analysis when a resident gets a pressure ulcer. The clinical record lacked documentation of an IDT meeting nor a Root Cause Analysis to determine how Resident 5 sustained a Stage III pressure ulcer on her upper left back. On [DATE] at 10:15 a.m., the Registered Nurse Consultant provided the facility's policy, Wound Nurse: What to do for New Skin issues and Week to Week Monitoring undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Obtain all physician notes from rounds . Information related to wounds must be taken to the weekly SWAT meeting for review with the IDT team . Upon notification of the physician, obtain a treatment order . A copy of the Interdisciplinary Team Meeting (IDT) notes were asked for from the ADON and not received by survey exit. 3XXX,d+[DATE](a)(1) 3XXX,d+[DATE](a)(2)

Based on interview and record review, the facility failed to ensure staff followed a resident's plan of care for transfers, staff did not perform tasks outside of their scope of practice, and therapy trained appropriate staff which resulted in a systemic failure and a residents fall with bilateral hip fractures for 1 of 5 residents reviewed for accidents. (Resident B) The Immediate Jeopardy began on 1/18/22 when the facility failed to ensure the resident was safely transferred by qualified staff which resulted in the resident being lowered to the ground. On 1/19/22, the resident began to experience pain and a mobile x-ray was performed at the facility which revealed a broken left hip. The resident was immediately sent to the hospital where it was discovered the resident sustained bilateral hip fractures which required surgical intervention. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/16/22 at 12:20 p.m. The Immediate Jeopardy was removed on 2/18/22, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 2/14/22 at 1:00 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to: [CONDITION(S)] (swelling in a limb caused by a lymphatic system blockage), muscle weakness, abnormal posture, weakness, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints), polyneuropathy (a condition which causes a decreased ability to move or feel sensation because of nerve damage), generalized [CONDITION(S)] (swelling), history of falling, and lack of coordination. Resident B's Quarterly MDS (Minimum Data Set) assessment, dated 1/5/22, indicated the resident was cognitively intact and was totally dependant upon the physical assistance of 2 or more staff for transfers; including from bed to a standing position. A fall risk assessment, dated 11/12/21, indicated the resident was non-ambulatory and was a high risk for falls. A fall risk care plan, initiated on 4/2/18 and current through 4/5/22, indicated the resident required a Hoyer life (a mechanical lift used by caregivers to safely transfer patients) only with transfers. The physical therapy note, dated 1/18/22 at 1:33 p.m., indicated extensive training with staff regarding proper placement of feet in stand up lift. Staff would need continued training for safety and ability to identify incorrect foot/leg placement for the resident prior to attempting transfers. The resident was very tearful on this day. The staff educated was TNA 1. The nursing note, dated 1/18/22 at 9:10 a.m., indicated a CNA (Certified Nurse Aide) transferred the resident to a chair using a sit to stand mechanical lift. The resident was not able to bear weight to their legs and began to droop in the lift. The resident was then lowered to the floor in a seated position on the buttocks, with their feet straight out, and ankles crossed. The CNA mentioned in the note was TNA (Temporary Nurse Aide) 1. The virtual health visit progress note, dated 1/19/22 at 1:21 p.m., indicated the resident was yelling and crying out in pain and Tylenol was not controlling the pain. The resident complained of pain being a 10 out of 10 (with a 10 being the worst pain) from the left hip to the ankle. The nursing progress note, dated 1/19/22 at 1:57 p.m., indicated a new physician's order was received for the resident to have a lower left extremity x-ray and [MEDICATION(S)] (a narcotic pain medication which can treat moderate to severe pain) 50 milligrams every 6 hours for pain. The x-ray result indicated the resident had a left femoral neck fracture, and the resident was sent to the hospital. The nursing progress note, dated 1/19/22 at 7:30 p.m., indicated the x-ray was obtained on the resident's lower left extremity. The nursing progress notes, dated 1/19/22 at 8:15 p.m., indicated the resident's x-ray results were back and the doctor wrote an order for the resident to be sent to the hospital. The fall event, dated 1/18/22 at 9:40 a.m., indicated the resident was unable to bear weight while in the stand lift and was lowered to the floor. When the nurse entered into the resident's room, the resident was found in the upright position with her back against the bed, their buttock resting partially on the foot rest of the stand lift, and their feet out in front, with their ankles crossed to the right of the stand lift frame. The mobile x-ray report, dated 1/19/22 at 7:32 p.m., indicated the resident had a fractured left femoral neck. The ED (emergency department) note, dated 1/19/22 at 9:43 p.m., indicated the resident was brought to the hospital and was experiencing hip pain following the fall. The resident stated the staff was getting them up using a lift but the resident was not sitting in it correctly. The resident tried to tell the staff to stop, however, the staff kept going and the resident fell out of the lift. A physical exam revealed the resident's right leg was shortened and externally rotated. A medical doctor note, dated 1/20/22 at 8:53 p.m., indicated the resident was in significant pain, the right leg was externally rotated and shortened, both hips were tender, the resident had sustained bilateral hip fractures, and needed urgent orthopedic consultation. An orthopedic doctor note, dated 1/21/22 at 10:44 a.m., indicated the resident required surgical intervention for bilateral hip fracture repair. A hospital x-ray, dated 1/19/22, indicated the resident sustained a displaced left femoral neck fracture and a possible right introtrochanteric femoral neck fracture. A CT scan (computed tomography scan was a medical imaging technique used in radiology to obtain detailed internal images of the body for diagnostic purposes) was recommended for better evaluation. A CT scan, dated 1/20/22 at 1:24 a.m., indicated the left femoral neck and femur was severely comminuted (producing multiple bone splinters) and mildly displaced. The right femoral neck was also comminuted and minimally displaced. During an interview on 12/14/22 at 11:40 a.m., the facility Administrator indicated CNAs and TNA were not to work outside of their defined scope of practice, which included solo transfers. During an interview on 2/15/22 at 11:55 a.m., Physical Therapist Assistant (PTA) 1 indicated the resident had been utilizing the sit to stand lift beginning on 1/11/22 and she educated TNA 1 on utilizing the sit to stand lift with Resident B. She indicated she never would have educated TNA 1 on lift usage had she had known she was not a CNA, as TNA are not allowed to perform that task alone. The resident was to be assisted by no fewer than 2 staff members in using the lift. If their feet were not accurately placed in the proper position by staff, the resident would not be able to utilize the lift. During an interview on 2/15/22 at 12:15 p.m., CNA 2 indicated on the morning of 1/18/22, TNA 1 entered the hallway outside of the resident's room and asked for help. Upon entering the room, the resident was observed in the sit to stand lift with the lift sling around her waist, arms in the air, and their feet crossed at the ankles. The resident was lowered to the floor. Additional nursing staff entered the room to transfer the resident with a Hoyer lift to her wheelchair. The resident indicated there was pain in both legs. TNA 1 had attempted to transfer the resident with the sit to stand lift without the help of other staff. The resident is to be transferred with the physical assistance of 2 staff due to muscle weakness. During an interview on 2/15/22 at 2:25 p.m., the Director of Nursing indicated TNA 1 would not have been able to transfer the resident using the sit to stand lift without the assistance of other staff due to the resident's larger body mass and instability. During an interview on 2/15/22 at 3:00 p.m., TNA 1 indicated she was by herself when she attempted to transfer the resident using a sit to stand lift. She thought it was a bad idea due to the resident's size and instability, but she was told the resident was no longer using the Hoyer lift for transfers, and she needed to only use the sit to stand lift. She locked the brakes and once she got the resident up, their ankles started to cross over each other so she lowered the resident onto their bed. She went to get another staff member to help and by the time she got back to the room, the resident was slipping off of their bed. She indicated she felt like she needed to do it on her own since it was very hard to find staff to help her out with transfers. During an interview on 2/16/22 at 2:10 p.m., Resident B indicated on 1/18/22 there was one staff member in the room who attempted to put them in the sit to stand lift without additional staff assistance. The resident's feet became tangled while the staff tried to get them into the lift. When the staff member went for help, another staff came to lower her to the floor from the lift. She had pain in her left and right legs and ankles following the incident. A review of TNA 1's competency check-off list, dated 12/22/21, indicated she was trained on how to transfer a resident. During an interview on 2/17/22 at 11:10 a.m., the DON indicated she completed the competency training with TNA 1 utilizing the Indiana State CNA training class material. The TNA and was educated on proper usage of transfer lifts, with the assistance of another staff member; never by herself. All residents who were transferred using a transfer lift required the operation of 2 staff members. On 12/14/22 at 1:50 p.m., the Indiana Department of Health Emergency Order Authorizing Temporary Personal Care Attendant Positions and Training for Nursing Homes, dated March 21, 2020, indicated .for anything beyond a one-person transfer, the PCA may only assist and must only assist and must be directed by a certified/licensed staff member . On 2/15/22 at 12:02 p.m., PTA 1 provided the user manual, RPS350-1 Stand Up Patient Lift, revised on November, 2013, and indicated it was the policy currently being used by the facility. A review of the manual indicated staff was to not lock the casters (breaks) during the lift of an individual. The casters needed be left unlocked to allow the lift to stabilize during lifting procedures. On 2/16/22 at 10:09 a.m., the DON provided a policy, Sit to Stand Lift, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated lift operation required a minimum of one trained operator. The Immediate Jeopardy, that began on 1/18/22, was removed on 2/18/22 when the DON in-serviced staff on proper usage of mechanical lifts and staff working within their scope practice, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaints IN 385 and IN 369. 3.1-45(a)(2)